Scrutiny of Ky. managed-care firms urgent


Timely access to treatment is critical if the commonwealth wants to contain health-care costs.

All health-care providers expect reasonable payment for their services and, with the evolution of how health care will be paid for, practitioners will need to demonstrate quality outcomes in order to receive full payment.

Most health care practitioners are dealing with acute effects of chronic illnesses. In order for treatment to be most effective and least costly, timely access to care is critical.

That’s why the state needs stronger oversight over Medicaid managed care companies, which have high profits while patient care suffers and providers are financially burdened and often stop accepting patients.

When the trip to see a primary-care provider assigned by the managed care organization is 45 minutes away and timely appointments are nonexistent, patients feel compelled to use emergency rooms. Logic would dictate that if the MCOs are providing timely care, the number of ER visits would decrease.

The July 2016 Kentucky Hospital Utilization Report clearly shows an increase of 27,984 ER visits in Western Kentucky compared to 2010, the year prior to inception of Medicaid managed care in Kentucky.

During this same time period, emergency rooms statewide experienced an increase of 77,930 patient visits. So, it appears access to care has worsened, resulting in increased costs because Medicaid recipients are using ERs for primary care services. Hospitals end up shouldering this burden.

The state auditor in 2015 reported MCOs were falling short of their contractual obligations. Yet billions of taxpayer dollars are being spent without effective oversight.

In 2015, Kentucky taxpayers paid $600 million above the national average to MCOs. Profits now are driving the health-care system at the expense of patient care and taxpayer dollars. An independent investigation needs to ascertain why substantial profit made by the MCOs happened in the first place, as opposed to directing these funds to the provision of health care.

Gov. Matt Bevin’s proposal, Kentucky Health, examines the MCOs’ profit margins in order to gain control of Medicaid costs. On page 13, the governor states, “The State has already taken a critical look at its managed care contract rates, as Kentucky MCOs have the highest profit margin of any state Medicaid program in the nation.” He further states that the commonwealth “will continue to make several additional contract reforms to reduce the inflated managed care profits which are nearly five times the national average.”

Current Kentucky Department for Medicaid Services compensation policy fails to adequately reflect the level of services being provided to Medicaid recipients. While the federal government sets payment rates based on factors such as geographic location, practice expenses and actual clinical work. Kentucky policy mandates that the MCOs pay for these more intensive services at lower rates after the first two visits.

The result is fewer health care providers willing to accept Medicaid, thereby making an already serious problem much worse.

Timely accessibility to quality health care strengthens Kentuckians. Prevention comes with a price; by investing in prevention the commonwealth circumvents the astronomically higher costs it would face without it. Further, Kentucky regulations need to reflect reality, not medical and financial hypotheticals, in order to provide Kentuckians quality and timely health care services.

Larry Suess of Hanson is a child psychiatrist.